1 minute
You may fill out an LGBT Health and Wellness Intake Form if you identify as lesbian, gay, bisexual, transgender, queer, questioning, or intersex.
How do you identify your gender?
What is your age?
What is your current relationship status?
Do you have any children?
What is your occupation?
What is your highest level of education?
Are you sexually active?
Do you have any sexually transmitted infections?
Do you have any allergies?
Do you have any chronic health conditions?